Ashtanga Hrudaya Sutra Sthana Chapter 18: Vamana Virechana Vidhim Adhyayam (Emesis and Purgation Therapies)

Persons suitable for Vamana procedure – Vamana Arha

विशेषेण तु वामयेत्||१||
नवज्वरातिसाराधःपित्तासृग्राजयक्ष्मिणः|
कुष्ठमेहापचीग्रन्थिश्लीपदोन्मादकासिनः||२||
श्वासहृल्लासवीसर्पस्तन्यदोषोर्ध्वरोगिणः|
Emesis should be administered to persons suffering from
Navajwara – fever of recent origin
Atisara – diarrhoea, dysentery
Adha:pitta – Pitta imbalance in lower part of abdomen
Pittasruk – Bleeding disorder due to Pitta imbalance
Rajayakshma – Chronic Respiratory disorder
Kushta – skin diseases
Meha – diabetes, urinary tract disorders
Apachi, Granthi – Goitre, tumour, fibroid
Shleepada – Elephantiasis, Filariasis
Unmada – Schizophrenia
Kasa – cough, cold
Shwasa – Chronic Respiratory tract disease, Asthma
Hrullasa – nausea
Visarpa – herpes
Stanyadosha – vitiated breast milk
Urdhvaroga – diseases affected neck and above region

Persons not suitable for Vamana – Vamana Anarha

अवाम्या गर्भिणी रूक्षः क्षुधितो नित्यदुःखितः ॥ ३ ॥
बालवृद्धकृशस्थूलहृद्रोगिक्षतदुर्बलाः ।
प्रसक्तवमथुप्लीहतिमिरकृमिकोष्ठिनः ॥ ४ ॥
ऊर्ध्वप्रवृत्तवाय्वस्रदत्तवस्तिहतस्वराः ।
मूत्राघात्युदरी गुल्मी दुर्वमो ऽत्यग्निरर्शसः ॥ ५ ॥
उदावर्तभ्रमाष्ठीलापार्श्वरुग्वातरोगिणः ।
ऋते विषगराजीर्णविरुद्धाभ्यवहारतः ॥ ६ ॥
प्रसक्तवमथोः पूर्वे प्रायेणामज्वरो ऽपि च ।
धूमान्तैः कर्मभिर्वर्ज्याः सर्वैरेव त्वजीर्णिनः ॥ ७ ॥
Garbhini – The pregnant woman,
Rooskha – persons who are dry –not undergone oleation therapy,
Kshudhita – hungry,
Nitya Dukhita – constantly grief–stricken,
children, old persons,
Krusha – the emaciated,
Sthula – the obese,
Hrudrogi – patient of heart disease,
Kshata – the wounded,
Durbala – weak, debilitated,
who are having bouts of vomiting,
Pleeha – enlargement of spleen,
Timira – blindness,
Krimikoshta – intestinal parasites,
upward movement of vata and Asra– blood,
Soon after administration of Vamana,
who have loss of speech, dysuria,
Udara – ascites, intestinal obstruction, tumour of the abdomen,
who faced difficulties during Vamana therapy,
who have strong digestive activity,
Arsha – haemorrhoids
Urdhva Vata – upward movement of air – reverse peristalsis,
Giddiness / Dizziness – enlargement of the prostate,
Parshvavata – pain in the flanks and diseases caused by vata;
Person suffering from poisoning,
indigestion and who have consumed incompatible foods.

Persons not suitable for Virechana– Virechana Arha

विरेकसाध्या गुल्मार्शोविस्फोटव्यङ्गकामलाः ।
जीर्णज्वरोदरगरच्छर्दिप्लीहहलीमकाः ॥ ८ ॥
विद्रधिस्तिमिरं काचः स्यन्दः पक्वाशयव्यथा ।
योनिशुक्राश्रया रोगाः कोष्ठगाः कृमयो व्रणाः ॥ ९ ॥
वातास्रमूर्ध्वगं रक्तं मूत्राघातः शकृद्ग्रहः ।
वाम्यश्च कुष्ठमेहाद्याः
persons suitable for purgation therapy:–
Diseases requiring purgation therapy are–
Gulma – Tumours of the abdomen,
Arsha – Piles,
Visphota– blisters,
Vyanga – discoloured patch on face,
Kamala – Jaundice, Liver disease
Jeernajwara – Chronic fever,
Udara – ascites, intestinal obstruction
Poisoning, Chronic poisoning
Chardi – Vomiting
Pleeha – Disease of the spleen, Splenomegaly,
Haleemaka – advanced jaundice,
Vidradhi – Abscess
Timira – blindness,
Kacha, Syanda – Cataract
pain in the large intestine,
Diseases of male and female uro–genital system
wounds/ Ulcers,
Vatasra – Gout,
Urdhwarakta – bleeding disorders of upper parts of the body (such as nasal bleeding)
Diseases of blood vitiation,
Mutraghata – Dysuria
Shakrut graham – constipation
Those persons who are Suitable for emesis therapy– enumerated in earlier verses commencing with “ those suffering from Kustha” are curable– to be treated with purgation therapy. 8–10a
Those diseases are –
Kushta – skin diseases
Meha – diabetes, urinary tract disorders
Apachi, Granthi – Goitre, tumour, fibroid
Shleepada – Elephantiasis, Filariasis
Unmada – Schizophrenia
Kasa – cough, cold
Shwasa – Chronic respiratory tract disease, Asthma
Hrullasa – nausea
Visarpa – herpes
Stanyadosha – vitiated breast milk
Urdhvaroga – diseases affecting neck and above region

Benefits of Samsarjana Karma

यथाऽणुरग्निस्तृणगोमयाद्यैः सन्धुक्ष्यमाणो भवति क्रमेण ।
महान् स्थिरः सर्वपचस्तथैव शुद्धस्य पेयादिभिरन्तराग्निः ॥ ३० ॥
Just as a spark of fire after being fed by grass, powder of dry cow dung etc, gets augmented gradually and becomes great, steady, and capable of burning everything, similarly, the internal digestion fire, by the Samsarjana regimen, in the patient who has undergone Vamana karma, gains strength. 30

Vega Samkhya– Mana– Number of Bouts and quantity

जघन्यमध्यप्रवरे तु वेगाश्चत्वार इष्टा वमने षडष्टौ ।
दशैव ते द्वित्रिगुणा विरेके प्रस्थस्तथा स्याद्द्विचतुर्गुणश्च ॥ ३१ ॥
For Vamana,
Heenayoga – Minimum bouts – 4 bouts
Madhyamavega – Moderate – 6 bouts
Atiyoga – Maximum bouts – 8 bouts
For Virechana –
Heenayoga – 10 bouts of purgation or half prastha of purgated material (384 grams)
Madhyamayoga – 20 bouts – 1 prastha of material (768 grams)
Atiyoga – 30 bouts. – 2 prastha (1,536 grams).

Expulsion of Kapha and Pitta

पित्तावसानं वमनं विरेकादर्द्धं कफान्तं च विरेकम् आहुः ।
द्वित्रान् सविट्कान् अपनीय वेगान् मेयं विरेके वमने तु पीतम् ॥ ३२ ॥
Vomiting therapy is allowed till the expulsions of pitta,
Purgation therapy is allowed till Kapha comes out;
Measurement to be done after rejecting 2 – 3 bouts, containing faeces in case of Virechana and after rejecting the medicine– emetic Drug in case of Vamana.

Virechana Vidhi– Purgation therapy procedure

अथैनं वामितं भूयः स्नेहस्वेदोपपादितम् ।
श्लेष्मकाले गते ज्ञात्वा कोष्ठं सम्यग्विरेचयेत् ॥ ३३ ॥
After Vamana therapy, patient is given Samsarjana regimen. After that, he is again given Snehana and Swedana treatment.
After that, in the morning, after Kapha time has lapsed (after around 9 – 10 am,) Virechana medicine should be given. The kind and quantity of purgation medicine should be determining the nature of his Kostha (alimentary tract, bowels).

बहुपित्तो मृदुः कोष्ठः क्षीरेणापि विरिच्यते ।
प्रभूतमारुतः क्रूरः कृच्छ्राच्छ्यामादिकैरपि ॥ ३४ ॥
A person with predominant pitta is considered Mrudukoshta (soft intestines), In these people even milk will induce purgation.
A person with predominant vata is considered Krurakoshta, (hard bowels, intestines), In these people even Trivrit (a purgative herb) might cause purgation with great difficulty.

कषायमधुरैः पित्ते विरेकः कटुकैः कफे ।
स्निग्धोष्णलवणैर्वायौ
For Pitta disease, Kashaya – astringent and Madhura – sweet drugs should be used for purgation.
For Kapha disease, Katu (pungent) herbs should be given for purgation.
For Vata, drugs with Snigdha – unctuous, oily, Ushna (hot) and Lavana (salt) taste should be given to induce purgation.

अप्रवृत्तौ तु पाययेत् ॥ ३५ ॥
उष्णाम्बु स्वेदयेदस्य पाणितापेन चोदरम् ।
If bouts of purgation do not commence, he should drink hot water and his abdomen should be fomented with palms of the hand, made warm.

उत्थानेऽल्पे दिने
तस्मिन्भुक्त्वान्येद्युः पुनः पिबेत् ॥ ३६ ॥
अदृढस्नेहकोष्ठस्तु पिबेदूर्ध्वं दशाहतः ।
भूयोऽप्युपस्कृततनुः स्नेहस्वेदैर्विरेचनम् ॥ ३७ ॥
यौगिकं सम्यगालोच्य स्मरन् पूर्वमतिक्रमम् ।
If, on the day of consuming the purgative drug, the patient responds poorly, he should be allowed to take his food on that day and the purgative drugs administered again on the next day;
Persons who have unstable and un–lubricated alimentary tract, should consume the purgative drugs after ten days – during which Snehana and sweating therapies should be done because the body which has been well prepared with Snehana and sweating therapies, will be able to have purgation properly;
then the purgative drug should be administered after considering all aspects and remembering the procedures described earlier.

Symptoms of weak purgation – Virechana Heena Yoga

हृत्कुक्ष्यशुद्धिररुचिरुत्क्लेशः श्लेष्मपित्तयोः ॥ ३८ ॥
कण्डूविदाहः पिटिकाः पीनसो वातविड्ग्रहः ।
अयोगलक्षणं योगो वैपरीत्ये यथोदितात् ॥ ३९ ॥
Discomfort in the region of the heart and abdomen, anorexia, exacerbation / excitation of kapha and pitta in the intestines (since they are not expelled properly following purgation) or expulsion of doshas i.e. kapha and pitta from the mouth, itching, burning sensation, eruption on the skin, rhinitis, obstruction of flatus and feces (constipation) are the symptoms of deficit purgation in case of proper administration of purgation, the opposite symptoms of the above mentioned are found.

Symptoms of excessive purgation – Virechana Atiyoga

विट्पित्तकफवातेषु निःसृतेषु क्रमात् स्रवेत् ।
निःश्लेष्मपित्तमुदकं श्वेतं कृष्णं सलोहितम् ॥ ४० ॥
मांसधावनतुल्यं वा मेदःखण्डाभमेव वा ।
गुदनिःसरणं तृष्णा भ्रमो नेत्रप्रवेशनम् ॥ ४१ ॥
भवन्त्यतिविरिक्तस्य तथातिवमनामयाः ।
After the elimination of feces, pitta, kapha and vata in successive order, there will be elimination of watery material devoid of kapha or pitta, which is white, black or slightly red in color, resembling the water in which meat has been washed or resembling a piece of fat prolapse of the rectum, thirst, giddiness, sunken eyes and diseases caused by excessive vomiting are the symptoms of excessive purgation.

After–care in purgation therapy – Virechana Paschat Karma

सम्यग्विरिक्तमेनं च वमनोक्तेन योजयेत् ॥ ४२ ॥
धूमवर्ज्येन विधिना ततो वमितवानिव ।
क्रमेणान्नानि भुञ्जानो भजेत् प्रकृतिभोजनम् ॥ ४३ ॥
The person who has undergone proper purgation therapy should be administered with all other therapies described in emesis therapy, except inhalation of medicated smoke later, he should follow the same procedure of dietetic regimen in the same way as of emesis therapy and then resume his normal food.

Indications for fasting in the after–care of purgation therapy – virechana paschat kale langhana yogyah

मन्दवह्निमसंशुद्धमक्षामं दोषदुर्बलम् ।
अदृष्टजीर्णलिङ्गं च लङ्घयेत् पीतभेषजम् ॥ ४४ ॥
स्नेहस्वेदौषधोत्क्लेशसङ्गैरिति न बाध्यते ।
On the day of consuming the purgation medicine, if the patient experiences (one or more of the) weak digestion,
coated feeling inside the gut due to deficit bouts, absence of emaciation caused by elimination therapy (purgation here), debility due to increase of doshas and
absence of symptoms of digestion of medicines, he should be put on fasting. Following fasting, he will not be harmed by the obstruction caused in the channels by the doshas which have been exacerbated due to oleation and sudation (but not been expelled).

Importance of graduated liquid diet – Peyadi Samsarjana

संशोधनास्रविस्रावस्नेहयोजनलङ्घनैः ॥ ४५ ॥
यात्यग्निर्मन्दतां तस्मात् क्रमं पेयादिमाचरेत्।
The digestive activity becomes weak by administration of purification therapies bloodletting therapy, oleation therapies and fasting, Hence, the regimen of thin gruel etc. should be followed (to kindle the digestive activity).

Importance of nourishing therapy – Tarpanadi krama

स्रुताल्प पित्तश्लेष्माणं मद्यपं वातपैत्तिकम्॥४६॥
पेयान्न पाययेत्तेषां तर्पणादिक्रमोहितः।
Thin gruel should not be given when (in those in whom) only small quantities of pitta and kapha are expelled out,
to alcohol addicts, and to those in whom vata and pitta are predominant for these people, nourishing therapy etc. are suitable (should be administered).

Status of expelled doshas in vomiting and purgation treatments

अपक्वं वमनं दोषान् पच्यमानं विरेचनम् ॥ ४७ ॥
निर्हरेद्वमनस्यातः पाकं न प्रतिपालयेत् ।
Emesis treatment brings out the doshas in an unprocessed form whereas purgation therapy brings out the doshas which are in the process of being processed. Therefore, in case of emesis therapy, the physician should not wait for doshas to get processed.

Need of purgative foods – Bhedaniya bhojya

दुर्बलो बहुदोषश्च दोषपाकेन यः स्वयम् ॥ ४८ ॥
विरिच्यते भेदनीयैर्भोज्यैस्तम् उपपादयेत् ।
The person who is weak, who has a great amount of increased doshas in the body, would develop purgation on his own (even without consuming purgation medicine) as an effect of maturity of doshas (which happens spontaneously in these people). These people should be treated with foods which are purgative in nature.

Indications for administration of mild, strong and repeatedly small dose of purgatives

दुर्बलः शोधितः पूर्वमल्पदोषः कृशो नरः ॥ ४९ ॥
अपरिज्ञातकोष्ठश्च पिबेन् मृद्वल्पम् औषधम् ।
वरं तदसकृत्पीतम् अन्यथा संशयावहम् ॥ ५० ॥
हरेद्बहूंश्चलान् दोषान् अल्पान् अल्पान् पुनः पुनः ।
दुर्बलस्य मृदुद्रव्यैरल्पान् संशमयेत्तु तान् ॥ ५१ ॥
Durbala – People who are weak,
Shodhita – who have undergone cleansing therapy,
Alpadosha – who have small amount of imbalanced doshas,
Krusha – who are emaciated
Aparijnata Koshta – whose bowel nature is not known should be given mild purgative, in a small dose, it is ideal to give the medicine in small doses often, or else i.e. if large dose of medicine is given in these conditions, it creates a doubt of death the purgation drug given in (small and) repeated doses will eliminate the circulating abundant doshas little by little in a weak person, small quantity of doshas should only be mitigated by medicines which are mild acting and liquid.

Effects of doshas which are stagnated – Anirhrta Dosha

क्लेशयन्ति चिरं ते हि हन्युर्वैनमनिर्हृताः ।
The same doshas which are excessive in quantity trouble the person greatly and even cause death if (they are) not expelled out by purification treatments.

Preparation of patient having weak digestion and hard bowels for purgation therapy

मन्दाग्निं क्रूरकोष्ठं च सक्षारलवणैर्घृतैः ॥ ५२ ॥
सन्धुक्षिताग्निं विजितकफवातं च शोधयेत् ।
Mandagni – Person having weak digestion,
Krurakoshta – hard bowels,
Sa kshara Lavana – should be administered ghee processed with alkali and salt, (with this) when his digestive capacity gets increased and morbid kapha and vata get destroyed, he should be given purification therapies.

Indications for enema and suppository before purgation therapy

रूक्षबह्वनिलक्रूरकोष्ठव्यायामशीलिनाम् ॥ ५३ ॥
दीप्ताग्नीनां च भैषज्यम् अविरेच्यैव जीर्यति ।
तेभ्यो वस्तिं पुरा दद्यात्ततः स्निग्धं विरेचनम् ॥ ५४॥
शकृन्निर्हृत्य वा किञ्चित् तीक्ष्णाभिः फलवर्तिभिः ।
प्रवृत्तं हि मलं स्निग्धो विरेको निर्हरेत् सुखम्॥५५॥
Rooksha – In persons who are dry,
Bahu Anila – who have great increase of vata,
Krura koshta – who has hard bowel,
Vyayama sheelina – who are indulged in exercise regularly and
Deeptagni – who have strong digestion strength, the purgation medicine gets digested without producing purgation, for these people, an enema should be given first and then purgative medicine which is unctuous should be given or the feces should be removed first by using a strong rectal suppository. The unctuous purgation easily expels the doshas thus initiated in their movement

Indications for administering mild oleation before purgation therapy

विषाभिघातपिटिकाकुष्ठशोफविसर्पिणः ।
कामलापाण्डुमेहार्तान्नातिस्निग्धान् विशोधयेत् ॥ ५६ ॥
सर्वान् स्नेहविरेकैश्च रूक्षैस्तु स्नेहभावितान् ।
Visha, Abhighata, Persons who are suffering from poisoning, trauma,
Pitika – skin eruptions,
Kushta – skin diseases,
Shopha – inflammation / swelling,
Visarpa – herpes,
Kamala – jaundice,
Pandu – anemia and
Meha – diabetes / urinary disorders
should be given purgation therapy without administering too much oleation (small quantity of mild oleation is sufficient for these people). All of them should be given fatty / unctuous purgation; those who have had oleation earlier should be administered dry (non–unctuous) purgatives.

Use of oleation and sudation in between the cleansing measures

कर्मणां वमनादीनां पुनरप्यन्तरेऽन्तरे ॥ ५७ ॥
स्नेहस्वेदौ प्रयुञ्जीत स्नेहमन्ते बलाय च ।
In between (each) emesis etc cleansing therapies, oleation and sudation therapies should be used once again at the end of each therapy, oleation should be done to restore strength in the body

Note – this means to tell that oleation and sudation should be interspersed in between each cleansing therapy, like oleation and sudation should be done before emesis, in between emesis and purgation, in between purgation and enema therapy etc.

Similey for understanding cleansing treatments

मलो हि देहादुत्क्लेश्य ह्रियते वाससो यथा ॥ ५८ ॥
स्नेहस्वेदैस्तथोत्क्लिष्टः शोध्यते शोधनैर्मलः ।
Just like the dirt from the cloth gets cleansed by washing the cloth, similarly the doshas get loosened from the body getting excited by the administration of oleation and sudation therapies get expelled by administration of purification therapies.

Effects of purification therapies done without oleation and purgation therapies

स्नेहस्वेदावनभ्यस्य कुर्यात् संशोधनं तु यः ॥ ५९ ॥
दारु शुष्कमिवानामे शरीरं तस्य दीर्यते ॥ ५९ab॥
When the person undertakes cleansing / purification therapies (emesis and purgation) without undergoing oleation and sweating therapies. His body gets broken just like a dried log of wood (gets broken) when it is bent.

Benefits of purification therapies – Shodhana Phala

बुद्धिप्रसादं बलमिन्द्रियाणां धातुस्थिरत्वं ज्वलनस्य दीप्तिम् ।
चिराच्च पाकं वयसः करोति संशोधनं सम्यगुपास्यमानम् ॥ ६०a ॥
Clarity of mind, strength of the sense organs, stability of the tissues, kindled digestive power and slow ageing occur (as benefits) when purification therapies are properly undertaken.

इति श्रीवैद्यपतिसिंहगुप्तसूनुश्रीमद्वाग्भटविरचितायामष्टाङ्गहृदयसंहितायां सूत्रस्थाने वमनविरेचनविधिर्नामाष्टादशोऽध्यायः॥१८॥
Thus ends the 18th chapter of Ashtangahridaya Samhita Sutrasthana, named Vamana Virechana Vidhi Adhyayam, written by Shrimad Vagbhata, son of Shri Vaidyapati Simhagupta.